Targeting Waiting Times
2013
Citation: Ministry of Health. 2013. Targeting Waiting Times.
Wellington: Ministry of Health.
Published in November 2013
by the
Ministry of Health
PO Box 5013, Wellington 6145, New Zealand
ISBN 978-0-478-40285-8 (print)
ISBN 978-0-478-40286-5(online)
HP 5675
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Contents
What are health targets?
Shorter stays in emergency departments
Our target
Why this target is important
Valuing our patients’ time
Right care at the right time
Improving the way we work
Improved access to elective surgery
Our target
Why this target is important
It’s all about the patient
Fast track to recovery
Coordinated care for cardiac patients
Shorter waits for cancer treatment
Our target
Why this target is important
A personal approach
Looking after each other
Recovering at home after chemotherapy
The last word
Targeting Waiting Times 1
What are health targets?
Health targets are a set of national performance measures that are designed to improve the performance of key health services. The targets are a focus for action in areas of health that reflect significantpublic and government priorities.
There are six national health targets, three focus on patient access, and three focus on prevention.[1]
The Ministry of Health (the Ministry) and the district health boards (DHBs) are collectively responsible for achieving the health targets. Progress is reviewed quarterly and reported publicly in newspapers and on the Ministry and DHBs’ websites. Clinical leaders and experts have been appointed as ‘target champions’ to work with and provide support to the health sector for each of the respective health targets.
The set of six health targets is reviewed annually to ensure they are still relevant and align with health priorities.
The health targets do not cover all the key health priorities norshould they be viewed in isolation. Each health target should be seen within the context of the broader programme of workand health priority they are part of.
In this publication, we look at how DHBs and their staff are working to achieve:
- shorter stays in emergency departments (EDs)
- improved access to elective surgery
- shorter waits for cancer treatment.
Timely access improves outcomes, is preferred by patients and ultimately saves cost. Real gains continue to be made in all three of the access targets focused on in this publication as DHBs change and improve how they work.
Meeting the health targets requires whole-of- system improvements that span not just the hospital butprimary and community providers as well. Figures 1–3 highlight performancetrends in each of the target areas fromJuly 2009 to June 2013.
In this publication, we look at some of the initiatives, innovations, organisations and people that have contributed to the significant sector improvements seen in the three access-focused targets.
Shorter stays in emergency departments
The target is to have 95 percent of patients admitted, discharged or transferred from an emergency department within six hours. Therehasgenerally been steady and ongoing improvements in achieving this target yearon year. Emergency departments experience increased pressure on services overthe winter months, hence the relative drop in performance every July to September quarter. Even so, results for winter have continued to increase when compared with the same period the previous year.
Improved access to elective surgery
The target is to increase the volume of elective surgery by at least 4000 discharges per year. The target hasbeen met at the national level since October2009, in order to improve access on a population basis. Each individual DHB hasachieved its share of the national total.
Shorter waits for cancer treatment
The target is to have all patients who are ready-for-treatment waitless than fourweeks for radiotherapy or chemotherapy. Chemotherapy waittimes wereintroduced into the target from July 2012. Performance for this target hasbeen achieved at a national level since the four-week target was introduced in July 2011.[*]* (In March 2013, onepatient waited fourweeks and two days for chemotherapy).
Note: From July 2007the target was that patients would receive radiotherapy within eight weeks of the decision to treat. Thismoved to six weeks from July 2008 and fourweeks from January 2011. The target was expanded to include patients needing chemotherapy from July 2012.
Shorter stays in emergencydepartments
Our target
Ninety-five percent of patients will be admitted, discharged or transferred from an emergency department within six hours.
Why this target is important
Every year almost a million New Zealanders arrive at an emergencydepartment (ED) for treatment.
To make sure these people don’t spend too long waiting for the care they need, the Government introduced a target for reasonable timely care. Thistarget is to have 95 percent of patients admitted, discharged or transferred from ED within six hours.
Professor Mike Ardagh, National Clinical Director of Emergency Department Services, says thatthe target focuses on improving a patient’s experience by helping them receive the care they need without unnecessary delays.
‘The target is not just about the emergency department, it’s about the whole hospital. We want to make sure that all patients get the best possible care and are treated, discharged or admitted to a ward in an acceptable timeframe. And we’ve made incredibly goodprogress.’
Since the target was introduced in 2009, national performance has increased from80 to 93percent. That’s less waiting for everyone.
‘There’s no longer a DHB in New Zealand where a large number of people are staying longer than six hours in the emergency department,’ Professor Mike Ardagh says.
Thisachievement is despite the growing demand on emergency departments.
A ‘patient’s journey’ describes the steps a patient takes as they go through the hospital system, including going to the emergency department (sometimes referred by their general practitioner), moving through different partsof the emergency department, moving through different parts of the hospital (such as going for a CT scan, going to the operating theatre, spending time in a ward), and ultimately going home to be cared for by their GP again.
Understanding the patient’s journey is critical to achieving the target.
‘To avoid undue delays and duplication, DHBs have looked at what happens to their patients from the time they arrive at the emergency department. DHBs have improved care in the community and enhanced the discharge process. It’s a whole-of- system approach to ensurethat changes are done well and the results are genuine.’
Examples of how DHBs have improved care are explained further in the casestudies.
Professor Ardagh stresses that this approach is not about compliance or simply shuffling patients around to meet a target. It’s about quality care.
‘The time-based target is a guide to what is best for patients. Our clinicians are charged with ensuring that patients receive the best possible care. Achieving 93 percent fouryears after the target was introduced is exactly where we shouldbe. It shows that there hasbeen sustainable change.’
An approach which is based on the whole system of care enables DHBs to understand where the problems are and how best to address them.The three casestudies to followillustrate how teams of dedicated staff are looking at the patient journey and changing the way they workto improve the time it takes for patients to receive their care. There are many other examples that could have been chosen.
The number of emergency department presentations and hospital admissions will likely continue to increase, putting further pressure on emergency teams across the country. DHBs are getting ready to meet the challenge by following the progress of the patient’s journey, and looking at what happened and when, and what canbe done differently to improve the patient’s experience.
‘We will continue to workto improve the patient’s journey and ensure that everyone hasaccess to the care they need,’ Professor Ardagh says.
Valuing our patients’ time
No-one likes to wait, especially in an emergency. The Auckland DHB team took a close look at what patients were waiting for in the emergency department and have made a series of improvements to keep things moving.
‘In 2009, we had overcrowding and longwaits in the emergency department. We started totrack ourpatients’ time through the hospital and discovered a number of reasons why people were waiting,’ explains Performance Improvement Programme Manager Tim Denison.
The biggest challenge was the time it took to transfer and admit the patients into the wards. And that’s because the ward beds werefull – often because of delays in discharging patients.
‘When a doctor makes a decision to admit an emergency patient into hospital, they want to be ableto do so quickly. To make things better for patients, we’ve standardised the transfer process,’ says Nurse Manager Annemarie Pickering.
‘Once medical staff have made the decision about where their patient needs to go, all they need to do is look for the flow charge nurse. They wear a bright green top and have a designated space on the floor.Everyone knows that the flow charge nurse is the go-toperson for admitting, transferring or discharging patients. It’s ourway of making sure that the right patient is going to the right area with the right resources,’ Annemarie explains.
A patient from the emergency department is transferred to the ward once there hasbeen a verbal handover from the emergency department to the ward nurse, a system made easier with the introduction of a handover hotline.
Each ward hasa mobile phone specifically for handover so that, as soon as they need to, the emergency department nurse cantalkdirectly to the nurse whowill be taking care of the patient.
Once on the phone, nurses follow a treatment guideline called the ISOBAR tool, which guides the steps in the handover under the headings of:identification, situation, observation, background, action and read back.This tool is designed to improve communication between teams. Read back is critical because it confirms that the ward nurse understands the plan for the patient.
‘The handover hotline and ISOBAR have really sped things up. There used to be a lot of phone tag, waiting and guessing,’ explainsward 75 Charge Nurse Steven Stewart.
In each ward, the house surgeon, nurses, physiotherapists, occupational therapists and social workers gather each morning to have a quick meeting about the day’s plan.
‘The daily rapid round means we plan for the day and plan for the stay. We go through every patient and work through the diagnosis. If the patient knows they are leaving, they can get rides organised, we can organise tests and discharge, and beds are freed up for other patients,’ Steven says.
No-oneis staying in hospital anylonger than needed. Senior nurses canalso discharge patients following a strict criteria set by the patient’s doctor to allowmore people to go home to their families in the weekend or after hours.
After his motorbike accident, Leo Aspite observed the team approach in the ward first hand.
‘They’re a good team who are really compassionate. At each handover, all the nurses come along so everyone knows what is going on. They allow me to be part of the team. When we talk together, I can make a suggestion and talk about how I’m feeling.
‘Even though the doctors’ rounds go really quick and feel like a whirlwind, the junior doctor takes notes. That’s how the nurses know what’s happening. As a patient, I have to help them to help me. If I follow their guidance, then I’ll getfixed andgo home,’Leo says.
Withso much going on across the hospital, a website hasbeen created to provide real-time updates on bedoccupancies. The site shows what beds are available, the type of room and whether the room hasbeen cleaned and prepped. The website also shows expected discharges within the next fourhours.
‘We escalate the response once we see the pressure points. For example, a lot of admissions in the emergency department will mean a bunch of referrals. When this happens, we’ve got the flexibility to open additional wards and look for nursing staff immediately,’ Tim Denison says.
In 2009, there were 370 people who had to wait for over 24 hours to be admitted to the next location, an inpatient ward.Fastforward three years to 2012, and only one patient had to wait 24hours. Better still, the average waittime now is only 1 hour 20 minutes. That means people are no longer waiting in the emergency department to get the care they need.
‘The number of emergency department patients hasincreased by 25 percent from 44,000 in 2009 to 55,000 in 2012. That’s more people spending less time in the emergency department. The physical wallsare not changing, but the number of patients is,’ Tim Denison says.
Right care at the right time
Patients in Nelson Marlborough have consistently received some of the best emergency care in the country. That’s 44,361 peoplein 2012 who were admitted, discharged or transferred from the emergency department within six hours.
Even though the number of emergency patients hasincreased overthe years, Dr TomMorton, Clinical Director at Nelson Marlborough DHB attributes this consistency to ongoing fine-tuning and a commitment to patient care.
The six-hour target is in the best interest ofthe patients whoare attending the emergency department, according to Dr TomMorton. He says it’s not only a measure of the efficiency ofacute patient flow through the ED, it’s also about improving the quality of care.
‘Reducing the length of time patients spend in a crowded ED is better for the patients and better for the hospital. Medical literature has linked long stays in an emergency department to negative clinical outcomes, such as increased mortality and longer stays in hospital,’ Tom Morton says.
The target also helps us to understand the barriers to accessing the right care in the right place at the right time. It is a force behind the current drive to research areas that look at ways people whoexperience chest pains canbe fast tracked to the right services.
‘I’m very pleased with ourconsistent ranking, especially as the number of patients has increased overthis time. It shows the genuine commitment of ED staff towards developing strategies that will reduce the length of stays.’
TomMorton puts this improvement down to an increase in education and preliminary workearly on, analysing breaches to the six-hour target. In2010 he undertook a comprehensive18month audit of the ED target breaches to establish the causes.
‘For a couple of years, I looked at every incidence where patients breached the six-hour target and looked at the trends and where bottlenecks wereoccurring.’
Tomsays a breach of the target, meaning some patients waitlonger than six hours, is not always bad, and there are a significant number of cases where it’s appropriate to breach.
‘A patient might have to waitmany hours for a particular test result, butthis test may show that they cango home and avoid admission, which is a better outcome for both the patient and the hospital.’
Meeting the target is not just a goal for the emergency department; it’s a challenge shared by the entire hospital community, and everyone has a role in helping out.
‘With a concerted effort across both Nelsonand Wairau hospitals, we’ve improved both the efficiency of the ED and the number of patients that breach six hours,’ Tomsays.
It’s a whole of system response that streamlines the experience for patients and their families.
Wairau Hospital Emergency Department Charge Nurse Sharon North agrees and says that she quickly realised that the six-hour target is much better for the patients.
‘It’s not just about ED but the whole hospital.Thisis particularly important in the middle of winter when there are bedblocks and a lot of different medical conditions. By six hours,patients are ready to be in a ward bed. Something as simple as being in a ward bedwhere thereare better mattresses improves a patient’s stay,’ Sharon says.
The availability of ward beds can be a challenge for everyone, and a computer system like Hospital at a Glance makes the day’s planning easier. The computer system uses detailed data submittedfrom all the wards and departments, to show the workload and capacity on TV screens installed around Nelson and Wairau hospitals. This means all staff know thecapacity (beds and staff) across the district.
‘Nurses canlook up at anytime and see where there are beds available. It updates every12minutes and helps our planning. We can quickly identify when there is a code red and work around it,’ Sharon explains.
There is also a manual charge board that hasa length-of-stay column andshows where early discharges are expected.
‘The length-of-stay column is highlighted in red so that we cantrack breaches and trends and then make improvements,’ Sharon explains.
Ongoing improvements are part of the plan for Nelson Marlborough DHB and, for the patients, this is goodnews.
Improving the way we work
Over 96 percent of patients who come into an emergency department at Waitemata DHB are now admitted, discharged or transferred within six hours.
Thisis a dramatic turnaround from June 2009, when the facilities at North Shore Hospital weren’t up to scratch and patients werewaiting incorridors. Withonly 62 percent of patients meeting the six-hour target, it was the worst performing emergency department in New Zealand.
Performance in 2009 was substandard says Dr Willem Landman, Clinical Director Emergency Medicine for Waitemata DHB.